The Ethics of Procedural Education Under Pandemic Conditions.

BACKGROUND: The COVID-19 pandemic significantly disrupted emergency medicine residents' education. Early in the pandemic, many facilities lacked adequate personal protective equipment (PPE), and intubation was considered particularly high risk for transmission to physicians, leading hospitals to limit the number of individuals present during the procedure. This posed difficulties for residents and academic faculty, as opportunities to perform endotracheal intubation during residency are limited, but patients with COVID-19 requiring intubation are unstable and have difficult airways. Case Scenario: When PPE is being rationed, who should be the one to perform an intubation on a patient with respiratory failure from severe COVID-19? DISCUSSION: We examined this case scenario using the ethical frameworks of bioethical principles and virtue ethics. Bioethical principles include justice, beneficence, nonmalfeasance, and autonomy, and virtue ethics emphasizes the provision of moral exemplars and opportunities to exercise practical wisdom. Arguments for an attending-only strategy include the role of the attending as a truly autonomous decision maker and the importance of providing residents with a moral exemplar. A resident-only strategy benefits a resident's future patients and provides opportunities for residents to exercise character. Strategies preserving the dyad of attending and resident maintain these advantages and mitigate some drawbacks, while intubation teams may provide the most parsimonious use of PPE, but may elide resident involvement. CONCLUSIONS: There exist compelling motivations for involving senior residents and attendings in high-risk intubations during the COVID-19 pandemic. A just strategy will preserve residents' role whenever possible, while maximizing supervision and providing alternative routes for intubation practice.

Decreased hospital admissions through emergency departments during the COVID-19 pandemic.

STUDY OBJECTIVE: Emergency Department (ED) visits decreased significantly in the United States during the COVID-19 pandemic. A troubling proportion of this decrease was among patients who typically would have been admitted to the hospital, suggesting substantial deferment of care. We sought to describe and characterize the impact of COVID-19 on hospital admissions through EDs, with a specific focus on diagnosis group, age, gender, and insurance coverage. METHODS: We conducted a retrospective, observational study of aggregated third-party, anonymized ED patient data. This data included 501,369 patient visits from twelve EDs in Massachusetts from 1/1/2019-9/9/2019, and 1/1/2020-9/8/2020. We analyzed the total arrivals and hospital admissions and calculated confidence intervals for the change in admissions for each characteristic. We then developed a Poisson regression model to estimate the relative contribution of each characteristic to the decrease in admissions after the statewide lockdown, corresponding to weeks 11 through 36 (3/11/2020-9/8/2020). RESULTS: We observed a 32% decrease in admissions during weeks 11 to 36 in 2020, with significant decreases in admissions for chronic respiratory conditions and non-orthopedic needs. Decreases were particularly acute among women and children, as well as patients with Medicare or without insurance. The most common diagnosis during this time was SARS-CoV-2. CONCLUSION: Our findings demonstrate decreased hospital admissions through EDs during the pandemic and suggest that several patient populations may have deferred necessary care. Further research is needed to determine the clinical and operational consequences of this delay.

Patients with Mild COVID-19 Symptoms and Coincident Pulmonary Embolism: A Case Series.

INTRODUCTION: Frequent thrombotic complications have been reported in patients with severe coronavirus disease 2019 (COVID-19) infection. The risk in patients with mild disease is unknown. CASE REPORT: We report a case series of three individuals recently diagnosed with COVID-19, who presented to the emergency department with chest pain and were found to have pulmonary emboli. The patients had mild symptoms, no vital sign abnormalities, and were negative according to the pulmonary embolism rule-out criteria. CONCLUSION: This suggests that patients with active or suspected COVID-19 should be considered at elevated risk for pulmonary embolism when presenting with chest pain, even without common risk factors for pulmonary embolism.